workshop historytaking

OSCE-Aid Revision Workshops: History Taking

2015 www.osce-aid.co.uk

History taking

Overview: This is a role-play exercise based on a typical OSCE history taking station. In this typical scenario, the students will be given 10 minutes to take a short history from the patient, suggest a management plan and be questioned on key points in the scenario. This scenario focuses on a patient who is tired all the time a common presentation seen in exams. Format of the exercise:

10 minutes Carrying out scenario o Ask the student to read the instructions to the group. Check for questions. o Teacher as actor or alternatively you can pick a student as the actor go by

brief overleaf: 8 minutes o After 6 minutes of history taking, prompt the student to discuss the initial

investigations/management with the patient o After 7 minutes of history taking, ask the student to summarise and present

his/her history: 1 minute o Last minute: Teacher to press the student on an aspect of the history that

they elicited i.e.: If thyroid tests were mentioned;

What pattern of results you would expect?

What treatment regimen you might want to try in a hypothyroid patient?

How can hypothyroidism mimic many other illnesses/carry similar signs/symptoms?

If a mood disorder is focussed on (as it will be from the brief), press them on:

What they would do next. (i.e.: would you start them on an antidepressant/refer them for other help?).

What would you do if a patient was frankly suicidal (sectioning/informal admission to a psych unit/crisis team input/community support)? What other things are important to consider here (drug/alcohol abuse, risk to others and safeguarding).

5 minutes Feedback o Provision of feedback to the student via teacher and the group: particularly

focus on feedback of the students history taking/communication skills Pick one student to list 3 things they did well Pick one student to provide 3 things that could have gone better Pick one student to provide a champagne moment for the history

something standout; i.e. eliciting a difficult component to the history, or picking up on a clue dropped by the historian.

o Questions for the student (2-3) you could recommend questions they could ask in a future history

10 minutes Discussion

Discussion of the material covered in key learning points (overleaf) This would benefit from a big flipchart and a pen get the students to brainstorm

the areas you would like to see covered in the history.



Student instructions To be read out loud by the student to the group You are a GP on your second foundation year placement. Mr Hardwick has presented to you stating that he is tired all of the time. Please take a history focusing on relevant details and discuss the initial investigations you would like to perform with him. You have eight minutes to do this in total. You will have two minutes to discuss the case with the examiner.



Actors brief Mr Hardwick a somewhat gruff character, who might like to read a Haynes manual in his spare time. Work-focussed, and alone after his divorce of 6 months ago. Considers himself a coper, and capable of overcoming any task if he sets his mind to it, but willing to entertain idea that he has had a stressful time if approached with proviso that he remains a capable person. I promised my daughter that I would see the doctor she made the appointment for me and the least I could do for her was to come along. Background medical history: High blood pressure (on amlodipine 5mg). BMI of 40 Previous cholecystectomy (laparoscopic). Family history Father died of MI 79 Mother bowel ca. 82 Brother has type 2 diabetes. Recent life stressors Divorce of 6 months ago (she left for unknown reason very little contact since). Re-applying for job at work and recently taken out new mortgage to cover cost of new extension to house. I am a 57 year old man, and I work for an engineering firm. For the past 3 months Ive been having trouble getting going and Ive felt generally rubbish. Ive been struggling to motivate myself to get going at work. This is particularly frustrating, as were going through a re-structure and everyone is having to re-apply for their jobs. Its very stressful. Im falling behind, and I think colleagues are noticing that Im not my old self. My concentration is all off, and thats whats really concerning me I never used to be like that. Ive not been able to get to sleep at night, and when I do, I wake up really early (about 4 oclock, if asked). I tend to get up and try to plan for things at work over a cigarette, but I never get very far. I suppose I dont enjoy things like I used to anymore; but I think this is probably because Im focussed on work. My appetite is pretty unchanged. I havent noticed much weight loss, but I know I should lose quite a bit my daughter keeps on telling me. I havent really been in the mood for sex, if asked, but then Im an old bloke carrying a bit of weight and presume no one would really want to look at me if I did. Im having a bit more to drink than I used to probably three or four scotches (singles) to get to bed at night, but no more than that. Ive noticed my hair thinning recently, and my voice has been a little croaky over the last few days I thought it was just age, and smoking a bit more, respectively. I havent noticed feeling cold, but then my house is sensibly insulated. I have been peeing more recently Im getting up about twice a night and going 6-8 times a day, but I havent been extra thirsty if asked more about this, Ive been experiencing urgency, finding it difficult to work up a stream and get post mictural dribbling. My brother has type II diabetes. Ive not been getting particularly breathless at night or during the day. I do snore (my wife always used to complain), but I wouldnt be able to tell you if Ive ever stopped breathing at



night. I dont drop off at work, but do feel a bit sleepy after a meal. I would probably fall asleep if you put me in the passenger seat of a car, but not in the driving seat (at a red light). If approached correctly (i.e. acknowledgement that Ive been through some stresses recently that would impact anyone), I will accept the offer of seeing someone in the community, and will think about starting an antidepressant if offered. Im not suicidal only broad thoughts about it being easier if I wasnt around. Ive got my daughter and my job to live for, and I have plans to retire to the countryside.



Key learning points: Lethargy is a feature of many disorders, so a tired all the time history will mostly be about showing an examiner that you can structure your history to time in order to fit the main ones in, then tailor it to fit others pertinent to the patient you are presented with. Main ground to cover these should be covered with any patient presenting to you:

1. Thyroid disorder 2. Anaemia 3. Diabetes 4. Mood disorders/life stressors

Then go on to consider the following, depending on the patient you are presented with, and their risk factors:

1. Cardiac dysfunction (AF/failure) 2. Respiratory disorder (OSA/SHS) 3. Renal dysfunction (nephrotic/nephritic syndromes) 4. Infective (glandular fever, post viral fatigue syndrome) 5. Drugs (i.e. those of abuse, especially stimulants, and those prescribed by

doctors/OTC) Questions pertaining to the main risk factors/signs/symptoms for the aspects youve focussed on will show the examiner that you are thinking about the main causes. Then spend the last minute coming up with a series of investigations youd like to perform and agree this with the patient. This will probably run along the lines of Id like to do some blood tests to check your thyroid status, your blood sugars, your kidney function and the levels of haemoglobin in the first instance, then we might want to do some more tests of your heart and lungs if all of these are normal. If the patients presentation seems to be more life-stressor/mood-orientated, you can state that you would still like to do the tests to rule out an organic cause, but then plan to explore their coping strategies and most importantly, risk, with them. As with all GP consultations; remember to safety net if you have any more concerns, or if x gets worse, you can make an appointment to come and see me again Or if you are concerned about their risk levels, a referral to community mental health services (IAPS, or more acutely a crisis team) may be appropriate. NB: Chronic fatigue syndrome is a possible diagnosis in a tired all the time history, but perhaps not one to plump for in a short case. Show the examiner that you can exclude all of the other diagnoses first. If you like you could raise the possibility of chronic fatigue if all tests are negative, but state you would like to carry out tests of the more common causes first. Thyroid disorder: Hypothyroidism Risk factors: Women (6:1 F:M), over 40 years old, other autoimmune diseases such as viteligo, primary biliary cirrhosis (primary atrophic hypothyroidism/Hashimotos thyroiditis high antibody titres). Remember amiodarone therapy (amiodarone is iodine-rich and looks like T4; thus can suppress TSH; actual T4 is not released. Presenting symptoms/signs:



Lethargy, low mood, cold intolerance, constipation, hoarse voice, impaired thinking, myalgia, constipation, weakness, eventually dementia, weight gain, thinning of hair, loss of outer third of eyebrows (most sensitive sign), goitre (less common than in hyperthyroid) Investigations: High TSH and low T4, OR low TSH and low T4 (in secondary; very rare). Cholesterol and triglycerides also raised. (NB: Tx: levothyroxine low dose in elderly (25 microgram intervals), start at 100mcg in younger. Recheck TSH 12 weeks, recheck every 6 weeks to normal state and then yearly). Anaemia: Risk factors: This depends on the cause of anaemia common ones to think about: occult blood loss in older patients (leading to 2 week suspected cancer referral), menorrhagia in younger women, true nutritional causes (iron deficiency/B12 or folate def. in vegans or alcoholics), myelodisplastic disorders, thalassemia/sickle cell, and renal dysfunction. Presenting symptoms/signs: Lethargy, dizziness Pallor (conjunctival, or skin). If more severe tachycardia/palpitations, chest pains, breathlessness. IDA: koilonychia, angular stomatitis, glossitis, think about pica and especially craving ice (pagophagia) Investigations: FBC (microcytic, macrocytic, normocytic?), Iron studies (serum iron, TIBC, Ferritin)

Iron TIBC Ferritin

Iron def - + - Anaemia of CD - - + Haemolysis + - + Haemochromatosis + -/N +

Other investigations if patient is anaemic: LDH, reticulocytes, blood film, B 12, folate TFTs Diabetes Risk factors: Type 1: family history, younger age, other autoimmune conditions Type 2: obesity, age, ethnicity, male gender, poor diet and lack of exercise (though correlates more with simple obesity), FH (MODY) Presenting symptoms/signs: Lethargy, polyuria/nocturia, polydipsia. Increased risk of infections especially skin infections/thrush. Consider the more long-term risks present from diabetes: i.e. eye signs (cataracts, diabetic retinopathy), peripheral neuropathy (ulcers, skin infections), and kidney dysfunction. Can also present as DKA (type 1) or HONK (type 2) Investigations: Urine dip glucose +++ (can be protein too) Random blood glucose of over 11.1 (one with symptoms, two without) HbA1C of over 6.5% (or 48mmol/mol in new money).



IGT: fasting plasma glucose of less than 7, but between 7.8-11.1 on OGTT Also IFG fasting plasma glucose between 6.1-7. Mood disorders Risk factors: Life-stressors (The Holmes and Rahe stress scale this lists potential life stressors in order; you could check for the major ones), concurrent or past mental disorder (most likely depression), chronic physical health conditions, social isolation, age. Presenting symptoms/signs: Core symptomatic features: anhedonia, anergia, low mood most of the day, every day for 2 weeks or more. Core biological features: lack of sleep (plus early morning waking; though can be hypersomlenence in c.10%), lack of appetite/weight loss (though appetite can also be increased in c.10%), low libido most of the day, every day for 2 weeks or more. Remember that low mood may have been preceded, or can be followed by manic episodes: check for a history of bipolar. Investigations: As with all psychiatric disorders, you must first state that you would like to rule out an organic cause (i.e. by ordering the tests discussed above). Assessing for risk is the most important thing to do when youve established depression as most likely cause. Ask about suicidal intent. Others Cardiac: Likely to be older patients with a background of hypertension/MI/hypercholesterolemia/other cardiac risk factors AF/flutter ECG to diagnose. Failures R vs. left vs. congestive: breathlessness, swelling, exercise tolerance (MRC is a useful scale), chest pain. (then take a brief SOCRATES history to determine if cardiac in nature). Will always want to do an echo with potential for further tests thereafter e.g. MPS, angiography etc. if indicated. Respiratory: Main one to exclude is OSA/SHS. Obese people, unless central apnoea (rare). Do they snore (ask a partner or ask if a partner often sleeps in another room) Often witnessed episodes of apnoea (by family etc.). Tend to fall asleep during the day, and will awake feeling tired/unrested. Epworth Sleepiness Scale. ABG/VBG may show high bicarbonate/type 2 respiratory failure. Infective: Glandular fever: young people starting school/university for first time: ESR, C-reactive protein and monospot test. Atypical mononuclear cells on blood film. Post viral syndrome: recent infection; can take weeks to recover. Drugs: Started any new medication? Have a look at side effects of most prescription/OTC medication lethargy will be one of the main SE listed. Think about alcohol misuse: sleep pattern interruption. Amphetamines: cocaine and ecstasy/MDMA overuse



Renal dysfunction Do a urine dip looking for protein. U+Es will tell you creatinine levels (important to know baseline). This may suggest chronic kidney disease.

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